국민건강보험법상 상대가치점수 직권 조정의 합법성에 대한 법이론적 분석

Abstract

Current National Health Insurance Act of Korea states that medical care benefit cost shall be determined by contract between the President of National Health Insurance Corporation and the representative of each medical and pharmaceutical communities. However, in the case of non-conclusion of contract due to rupture of negotiations, Minister of Ministry of Health and Welfare has the authority to determine such expense via public notice. The aforementioned contract only deals with unit cost derived from relative value of each medical procedure which is determined by the Minister through public notice. Such contract can only perform as a half of a already half contract. Also, this contract’s substantiality can be severely damaged if the Minister compulsorily markdowns the relative value point after the contract has been concluded. This is where the ex officio markdown’s illegality becomes a problem. This problem should be solved by balancing two constitutional principles, principle of private autonomy and social security of health insurance, when interpreting the System of Contract on Medical Care Benefit Costs. The key points of such interpretation is as follows: First, ex officio adjustment system by public notice itself is allowable. Second, decrease in relative value point by ex officio markdown of relative value point should not be noticeable from the expected medical care benefit cost derived from Contract on Medical Care Benefit Costs. For if one had known that relative value point would decrease in distinguishable amount from what he expected from a conclusion of contract, no one would participate in a contracting process. Third, ex officio adjustment can only be allowed in case where amount of physician work, amount of resource, or practice expense needed for a medical act have changed significantly. Lastly, ex officio adjustment of relative value point must be preceded by reviewing process of Reviewing Committee of Specialists.